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Health Care Reform:

Health Insurance & Affordable Care Act

Pennsylvania Health Insurance Marketplace

Plans and Costs continued...

Go to HealthCare.gov to compare plan costs.

  • Bronze Plan: You pay 40% and the plan pays 60%.
  • Silver Plan: You pay 30% and the plan pays 70%.
  • Gold Plan: You pay 20% and the plan pays 80%.
  • Platinum Plan: You pay 10% and the plan pays 90%.
  • Catastrophic Plan: You pay 100% of a set amount of money called the deductible before the plan's coverage kicks in. Three primary care visits per year and preventive services are covered for free before you meet the deductible.

Within the metal levels are different types of plans, including:

HMO (health maintenance organization): You can only get treated by doctors in the plan's network (except in a medical emergency). You pay the full cost of care if you use a health care provider outside the network. You also need a referral from your primary care doctor before seeing a specialist.

PPO (preferred provider organization): You can see doctors and go to a hospital outside of your plan’s network for an additional cost. You generally do not need a referral before seeing a specialist.

POS (point of service): You can see doctors and go to a hospital outside of your plan’s network at an additional cost. You also need a referral from your primary care doctor to see a specialist.

EPO (exclusive provider organization): You are limited to doctors and hospitals that are part of your plan’s network (except in a medical emergency), but you generally do not need a referral before going to a specialist.

Costs: Costs of plans on the Marketplace vary based on your age, the number of people in your family, where you live, and your tobacco use. They cannot charge you more because of your sex or a pre-existing health condition.

What to Know When Choosing a Plan

Co-pay, Coinsurance, Deductibles, and Premiums: In addition to your monthly premium, here are other insurance costs to consider as you choose a plan:

  • Co-pay: A set amount you’ll pay for a health care service, such as a doctor visit
  • Deductible: The amount you need to pay before your coverage kicks in
  • Coinsurance: The percentage of costs you’ll pay for a health care service, such as a doctor’s visit
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